Healthcare Provider Details

I. General information

NPI: 1164765582
Provider Name (Legal Business Name): KEVIN ANDREW GRAVES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N 4TH ST
BARLOW KY
42024-9579
US

IV. Provider business mailing address

117 S 2ND ST
AUGUSTA AR
72006-2309
US

V. Phone/Fax

Practice location:
  • Phone: 270-334-3131
  • Fax:
Mailing address:
  • Phone: 870-347-2534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR2853
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number03661
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: